Provider Demographics
NPI:1013771229
Name:BLANCO, KATHERINE (APRN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5332 NW 198TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1661
Mailing Address - Country:US
Mailing Address - Phone:786-759-9453
Mailing Address - Fax:
Practice Address - Street 1:8260 W FLAGLER ST STE 2I
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2069
Practice Address - Country:US
Practice Address - Phone:786-715-9183
Practice Address - Fax:786-713-1115
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9557506363L00000X
FLAPRN11031063363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner